INSIDE THE ISSUE

> Workforce
> Narcan
> Sen. Warren on Medicare Advantage
> UHC’s Prior Auths
> 1.2 Seconds
> Transitions

MONDAY REPORT

HPC Delves into Workforce Issues; Cautions Raised on Contract Labor

The Health Policy Commission (HPC) held a half-day forum last Wednesday on what nearly the entire healthcare continuum agrees is its most serious problem – the recruitment and retention of the healthcare workforce.

The HPC released its comprehensive 98-page study on the issue, focusing specifically on registered nurses, direct care workers, and behavioral health providers. (The physician community in Massachusetts and around the U.S. is facing its own epidemic of burnout and doctors leaving the profession.)

The HPC found that “current healthcare workforce challenges stem in part from a tighter labor market that has motivated many highly skilled healthcare workers to leave their current roles in pursuit of higher pay from comparatively well-resourced organizations/sectors or in contract roles, or to redirect their careers from patient care to administration or research. At the same time, some lower-wage healthcare workers who provide critical support services have left healthcare entirely, finding more lucrative jobs or jobs in non-healthcare fields. There is also a continued statewide shortage of qualified behavioral healthcare professionals, at a time of significant need for these services.”

During the four-hour forum, which included two panels of speakers, some common themes emerged. First, resolving the issues of strengthening an education pipeline for healthcare workers, encouraging people to join the profession, changing traditional healthcare job inflexibilities, and investing more funding into the jobs will require an all-hands-on-deck approach. The spirit of cooperation that existed during the pandemic among providers, elected officials, regulatory agencies, organized labor, and others must be continued to resolve the workforce crisis, forum participants said.

Another key theme is that contract labor – the use of so-called nursing “traveler agencies” – must be addressed properly.

MHA’s President & CEO Steve Walsh, who participated on one panel and discussed MHA’s study showing hospitals spent $1.52 billion on contract labor in 2022 – a 600% increase over pre-pandemic expenditures – called the national traveler agency phenomenon “remarkable.” He said, “You could have a worker that is side by side with another worker. And they leave on a Monday and then on Tuesday one is rented back to the same facility at 4x or 3x pay, depending on demand. And one worker is right next to the worker they were with the day before. What does that do to morale?” Walsh, while conceding facilities need travelers to maintain care access, said “we have to put some guardrails around this” at the national level.

The HPC report details how experienced staff nurses must work additional hours to bring the traveler nurses up to speed, which is frustrating and causing nurses to leave their jobs. That extra administrative work takes their time away from the mentorship that new nurses require, so the new nurses may become frustrated and leave their jobs, which compounds the workforce shortages.

Following Wednesday’s meeting, Massachusetts Attorney General Andrea Campbell issued an advisory to the traveler agencies notifying them about permissible rates that may be charged to long-term care facilities. The AG said the advisory is needed because the office has received allegations that some agencies are engaging in “an unfair or deceptive act or practice” under the law.

Another theme emerging last Wednesday is the overall need to get more people – especially younger people and people of color – interested in tough, but rewarding and good-paying healthcare jobs. Several panelists spoke about the need for a “moonshot” mindset, with no idea too big or bold given the urgency of the issue. MHA’s Walsh floated the idea of an “AmeriCorps-type” strategy, where the healthcare system in cooperation with the state and other interests funds a person’s education and training in the healthcare field in return for that person agreeing to work for a set period in a Massachusetts healthcare facility.

Narcan to Become Readily Available Over the Counter

The U.S. Food and Drug Administration last Wednesday permitted the naloxone nasal spray known commercially as “Narcan” to be sold over the counter – that is, without a prescription. “We can prevent overdoses and save lives by making naloxone more accessible, and at the same time, we can ensure equitable access to essential healthcare,” said U.S. Health & Human Services Secretary Xavier Becerra.

An MHA-endorsed bill filed by Rep. Andy Vargas (D-Haverhill) – An Act Relative to Opioid Use Disorder Treatment and Rehabilitation Coverage – would require insurance companies to cover nasal naloxone (including Narcan) and buprenorphine without prior authorization or cost sharing, regardless of whether it is prescribed or dispensed directly to the patient. Currently, there are limited mechanisms for providers to be reimbursed for Narcan when dispensing directly to the patient, as is best practice, and no mechanism for reimbursing buprenorphine dispensed directly to the patient. This bill would increase the accessibility of these medications and assist in preventing opioid overdose deaths.

Sen. Warren Decries Medicare Advantage “Tricks”

Citing a letter from Donald Berwick and other health policy experts, Senator Elizabeth Warren (D-Mass.) last week called on the U.S. Department of Health and Human Services and the Centers for Medicare and Medicaid Services to take steps “towards addressing private insurers’ long history of exploiting the government out of billions of dollars.”

The policy letter Warren cites details how approximately 15% of any increased payments to Medicare Advantage (MA) plans are actually paid by beneficiaries in Traditional Medicare (TM) through increased Part B premiums.

“Without changes to the way Medicare pays MA plans … over the next 8 years MA plans will be paid approximately $960 billion, almost $1 trillion, more than Medicare would pay if beneficiaries remained in TM,” Berwick and his three colleagues wrote. “Taxpayers will be responsible for 85% of this amount. Medicare beneficiaries will pay for 15% or $145 billion of this through increased Part B premiums. This constitutes a major transfer of wealth from the Nation’s seniors to the owners of MA plans who will then decide how it will be used by their firms.”

In her letter to HHS and CMS, Warren denounced “the tricks that Medicare Advantage plans use to squeeze billions of extra dollars out of the Medicare program.”

In another letter signed with eight Senate colleagues, Warren criticized Medicare Advantage overcharges to the federal government and taxpayers “that threaten the solvency of the Medicare program and jeopardize access for Medicare beneficiaries.”

The Senators were especially critical of medical prior authorizations that meet Medicare coverage rules but are improperly denied by MA plans.

National Insurer Relents on Prior Auths – But Does It?

The large national insurance company, UnitedHealthcare (UHC) announced last Wednesday that starting this summer it will eliminate nearly 20% of its current prior authorizations, as part of what it says is “a comprehensive effort to simplify the healthcare experience for consumers and providers.” UHC also said that beginning in 2024 it will implement a “Gold Card Program” for certain trusted providers that will eliminate prior authorization requirements for most procedures.

Ironically, on March 14, UnitedHealthcare sent notice that it was increasing its prior authorization requirements for gastroenterology endoscopy services, beginning June 1, 2023. Affected procedures now requiring prior authorizations include esophagogastroduodenoscopies (EGD), capsule endoscopies, diagnostic colonoscopies, and surveillance colonoscopies.

Time to Make a Diagnosis? 1.2 Seconds

An eye-opening investigation by ProPublica details how doctors at one national insurer, Cigna, engage in rapid-fire “click and submit” denials of coverage without even reviewing a patient’s case.

“The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials,” ProPublica writes. “Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers healthcare plans for 18 million people.”

The article quotes one Cigna doctor, who said, ““We literally click and submit. It takes all of 10 seconds to do 50 at a time.”

Transitions

Jeffrey Brickman is the interim president of Anna Jaques Hospital, replacing Mark Goldstein, who stepped down from the top post on March 10. Brickman is the founding partner and manager of Nexxt Health Advisors, a management consulting firm. He served as president and CEO of Central Maine Healthcare from 2016 to 2021 and previous to that he was group president of Mountains and North Denver Operating Group of Centura Health. Brickman holds a bachelor’s degree in biological sciences from the University of Connecticut, and an MBA with an emphasis in healthcare administration from Temple University. Anna Jaques Hospital is part of Beth Israel Lahey Health, which announced a search is underway for a permanent president & CEO.

David Storto, the former president of the Spaulding Rehabilitation Network and current EVP and Chief Strategy & Growth Officer for Tufts Medicine, is leaving his post at the end of April to become Senior Health Care Executive Advisor at Tandem Solutions, a change management company. Storto previously served on MHA’s Board of Trustees.

John LoDico, Editor